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Insurance - Tunnelworks Services, Inc. - 2016-10-13 TUNNSER-01 FSTEPANIAN ACRO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#0G19762 CONTNAME:ACT Chris Ferraris Momentous Insurance Brokerage Inc PHONE 818 574-0424 FAX ) (818)574-0466 5990 Sepulveda Blvd.,#550 (A/C,No Ext:(818) (A/c,No Van Nuys,CA 91411 E-MAIL ADDRESS:chris.ferraris mmibi.com INSURER(S)AFFORDING COVERAGE n NAIC# INSURER A:California Automobile Insurance Company 38342 INSURED INSURER B: Tunnelworks Services Inc. INSURER C: 13502-H Whittier Blvd,Ste 165 INSURER D: Whittier,CA 90605 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXPLTR ADDLISUBIF_----- �'(POLICY EFF (POLICY E YY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE 'I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A X ANY AUTO X !BA040000019527 12/12/2015 12/12/2016 BODILY INJURY(Per person) $ I ----ALL OWNED I SCHEDULED BODILY INJURY(Per accident) $ AUTOS i AUTOS NON-OWNED PROPERTY DAMAGE - - �$ -- - -- - HIRED AUTOS I AUTOS (Per accident) UMBRELLA UAB OCCUR Ali EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER I AND EMPLOYERS'LIABILITY Y/N ,STATUTE ERH 'ANY PROPRIETOR/PARTNER/EXECUTIVE Et EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A ---- - ---- -- - -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Costa Mesa Sanitary District,its directors,officials,officers,employees,agents,and volunteers are named as an additional insured on the Auto Liability Policy per the attached form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 628 W 19th Street Costa Mesa,CA 92627 AUTHORIZED REPRESENTATIVE • ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD COMMERCIAL AUTO CA 20 48 02 99 POLICY NUMBER: BA040000019527 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organizations(s)who are"insureds"under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 10/10/2016 Countersigned by: Named Insured: TUNNELWORKS SERVICES INC (Authorized Representative) SCHEDULE Name of Person(s)or Organization(s): COSTA MESA SANITARY DISTRICT ITS DIRECTORS,OFFICIALS,OFFICERS, EMPLOYEES,AGENTT AND VOLUNTEERS 628 W 196TH ST COSTA MESA, CA 92627-2716 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an"insured"for Liability Coverage, but only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured Provision contacted in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 Business Auto 2008 97 10/14/2016 California Automobile Insurance Company-Company Profile-Best's Credit Rating Center A.M. Best Rating Services California Automobile Insurance Company (?) A.M.Best#:002646 NAIC#:38342 FEIN#:952971307 Mailing Address View Additional Address Information Revenelel P.O.Box 54600 43=0 1 Los Angeles,CA 90054 United States Assigned to insurance companies that have, Web:www.mercurvinsurance.com in our opinion,a superior ability to meet their ongoing insurance obligations. Phone:323-937-1060 Fax:323-857-7116 Based on A.M.Best's analysis,058411 -Mercury General Corooratlon is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure.View a list of ooeratina insurance entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: A+(Superior) Affiliation Code: g(Group) Financial Size Category: XII($1 Billion to$1.25 Billion) Outlook: Negative Action: Affirmed Effective Date: June 15,2016 Initial Rating Date: June 30, 1981 Long-Term Issuer Credit Rating View Definition Long-Term: aa- Outlook: Negative Action: Affirmed Effective Date: June 15,2016 Initial Rating Date: May 03,2006 u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by:A.M.Best Rating Services,Inc. Senior Director.Gregory T.Williams Disclosure Information F ■� View A.M.Best's Ratina Disclosure Form A.M.Best Revises Outlooks to Neaative and Affirms Ratings of Members of Mercury Casualty Group r June 15,2016 Rating History A.M.Best has provided ratings&analysis on this company since 1981. Financial Strength Effective Date Rating 6/15/2016 A+ 2/27/2015 A+ 1/31/2014 A+ 12/21/2012 A+ 10/31/2011 A+ http://www3.ambest.com/ratings/entities/SearchResults.aspx?AltSrc=9 1/3 10/14/2016 Company Profile C/1LIFGRNIA DEPARTMENT OF INSURANCE COMPANY PROFILE Company Profile Company Search Company Information Company Search Results CALIFORNIA AUTOMOBILE INSURANCE COMPANY Company 4484 WILSHIRE BOULEVARD Information LOS ANGELES, CA 90010 Old Company 800-824-6194 Names Agent for Service Old Company Names Effective Date Reference Information MERCURY INDEMNITY COMPANY 12/05/1988 NAIC Group List Lines of Business Agent For Service Workers' RANDALL PETRO Compensation 555 WEST IMPERIAL HIGHWAY Complaint and BREA CA 92821 Request for Action/Appeals Contact Information Reference Information Financial Statements PDF's NAIC #: 38342 Annual Statements Quarterly California Company ID #: — 2343-2 Statements 1Date Authorized in California: 12/12/1979 Company Complaint — - — Company LLicense Status: { UNLIMITED-NORMAL Performance & �_ _— Comparison Data Company Type: Property &Casualty Company Enforcement Action State of Domicile: CALIFORNIA Composite Complaints Studies back to top Additional Info Find A Company NAIC Group List Representative In Your Area View Financial NAIC Group #: 0660 MERCURY GEN GRP Disclaimer Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. AIRCRAFT AUTOMOBILE BOILER AND MACHINERY BURGLARY COMMON CARRIER LIABILITY CREDIT DISABILITY FIRE LIABILITY MARINE MISCELLANEOUS https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyProfile&doFunction=getCompanyProfile&eid=6081 1/2 r 4 �...a1 TUNNE-1 OP ID:SW A�Q- DATE(MWDDIYYYY► /'1 CERTIFICATE OF LIABILITY INSURANCE 10/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT N Cornerstone Commercial& PHONE FAX Personal Insurance Services INC.No.Ext): (NC,No): 7365 Carnelian St.Suite 225 ADDRESS: Rancho Cucamonga,CA 91730 Philip E Hakopian INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:SCIF INSURED Tunnelworks Services,Inc INSURER II:Colony Insurance Company Nicole Valdez INSURER C: 13235 Helmer Drive Whither,CA 90602 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAKED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADDLSUBIC POLICY EFF POLICY EXP um= LTR TYPE OF INSURANCE INSR VD POLICY NUMBER (MMIODM'YY) IMMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 910 103GL0006 -01 10/24/2015 10/24/2016 DAMAGE TO RENTED 100,000 B X COMMERCIAL GENERAL LIABILITY X X PREMISES fEa occurrence) $ 1 CLAMS-MADE X OCCUR MED EXP(My one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 _GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY f,PIFC07 fl LOC _ AUTOMOBILE LIABILITY (COMBINED idem) LE LIMB i_ BODILY INJURY(Per person) S ANY AUTO _ AUTOS NED X gUTOSULED BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS X AUTOS (PER ACCIDENT) S UMBRELLA LAB — OCCUR EACH OCCURRENCE $ EXCESS LAA• CLAIMS-MADE AGGREGATE S DED RETENTION$ S 1/yC STATUOTH- WORNERS COMPENSATION X TORY LIMITS- ER AND EMPLOYERS'WBIUTY1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A X 9099073-16 05/09/2016 05/09/2017 E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? I I E.L.DISEASE-EA EMPLOYEES 1,000,000 (Myyaaandatory in NH) DESCRIPTIONN OOF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Job11314 Grade 5 Phase 4 Repairs Certificate Holder, its directors, officers, employees, agents and volunteers are all named as Additional Insured's. General Liability Endorsement attached with WC Waiver of Subrogation to follow CERTIFICATE HOLDER CANCELLATION `T SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Costa Mesa Sanitary District AUTHORIZED REPRESENTATIVE 234 E 17th Street#205 lb-Jul-A& � Costa Mesa,CA 92627 lb-4+•■.- /'d -Ama I ©1988-2010 ACORD CORPORATION. All rights reserved. • ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 103 GL 0006910-01 EN DT.#002 EFF: 1010512016 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED.PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations The Costa Mesa Sanitary District,Its directors,officers, As required by written contract with Named employees, agents and volunteers Insured. 234 E 17th Street#205 Costa Mesa,CA 92627 Information required to complete this Schedule, if not shown above,will shown in the Declarations. A. Section II—Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s)or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for"bodily injury","property This insurance does not apply to "bodily injury"or • damage" or "personal and advertising injury" "property damage"occurring after. caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or merit furnished in connection.with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insureds) at the location of the the additional insured(s)at the location(s)desig- operations has been completed;or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 2010 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 • 4 103 OL 000691041 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the folowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resulting from your ongoing operations or r work"done under a that person or organization and included contract with in the "products-completed operations s hazard if: p opera a. you agreed to such waiver; b. the waiver is induded as part of a written contract or lease;and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U047-0310 Includes copyrighted material of ISO Properties, Inc., Page i of 1 with its permission. 103 GL 0006910.01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE N.ms a/Add tional Insured Person(s)or Organkatlon(s) (Additional insured): Loation(s)of Covered Operations: All persons or organizations as required by written As designated in written contract with the Named contract with the Named Insured Insured k SECTION II—WHO IS AN INSURED is amended to include as an additional insured the person(s)or organization(s)shown in the Schedule for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury","property damage"or"personal and advertising injury"caused, in whole or in part, by: 1. Your acts or omissions;or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "Bodily injury"or"property damage"for which the additional insured(s)we obligated to pay damages by reason of the assumption of liability In a contract or agreement. Finished Operations at Work "Bodily injury or"property damage"occurring after. 1. All work, indudamg materials, parts or equipment furnished in connection with such work, on the project(other than service,maintenance or repairs)to be performed by or on behalf of the additional insured(s)at the location of the covered operations has been completed;or U156P-0310 Includes copyrighted material of ISO Properties,Inc., Page 1 of 2 with its permission. 103 OL 0006910.01 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured insured(injury' u�or"property damage"arising directly or indirectly out of the negligence of the additional ). C. SECTION IV — COMMERCIAL GENERAL LWBWTY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured shown in the Schedule Is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, U156P-0310 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. 103 OL 000691041 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS,S, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION - COMPLETED OPERATIONS & ONGOING OPERATIONS AS SCHEDULED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Operations All persons or organizations as required by written Commercial,non wrap Projects only as designated {' contract with the Named Insured by written contract with the Named Insured A. Section II—Who Is An Insured is amended to include the persons)or organization(s)shown in the Schedule(called additional insured),but only with respect to: (1) Liability for"bodily injury"or"property damage" caused, in whole or In part, resulting from "your work" at the location designated and described in the schedule of this endorsement performed for that additional Insured and induded In the "products-completed operations hazard"when you and such person(s)or organization(s) have agreed in writing in a con- tract or agreement that such person(s) or organization(s) be named as an additional in- sured on your policy. (2)Liability for"bodily injury", "property damage'or"personal and advertising injury"caused, in whole or in part,by resulting from: (a)Your acts or omissions;or (b)The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the loca- tion(s)designated above. B. Section IV— Commercial General Uability Conditions, 4. Other Insurance is amended and the following added: If you are required by written contract to provide primary insurance, the insurance afforded by this Coverage Part for the additional insured shown in the Schedule Is primary insurance and we wil not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U462-0310 Includes copyrighted material of ISO Properties, Inc.,2004 Page 1 of 1 with its permission. • TUNNE-1 OP ID:SW • ACORO' DATE(MM/DG/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 10/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Cornerstone Commercial& PHONE FAX Personal Insurance Services INC.No.EMI: (A/G Nob 7365 Carnelian St.Suite 225 EMAIL Rancho Cucamonga,CA 91730 ADDRESS: Philip E Hakoplan INSURER(S)AFFORDING COVERAGE NAIC K INSURER A:SCI F INSURED Tunnelworks Services,Inc INSURER B:Colony Insurance Company Nicole Valdez INSURER C: 13235 Helmer Drive Whittier,CA 90602 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBW POLICY EFF POLICY EXP LTR TYPE OP INSURANCE INSR yyy0 POLICY NUMBER (MMIDD/YYYY) (MWDDIYYYY) LIMITS GENERAL LJABEJTY EACH OCCURRENCE S 1,000,000 B X COMMERCIAL GENERAL LIABILITY X X 103GL0006910-01 10/24/2015 10/24/2016 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(My one person) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —I POLICY FlJFC I I LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S _ ANY AUTO BODILY INJURY(Per person) S ALL OWNEDX NOSCHEDULED BODILY INJURY(Per accident) $ AUTOS N-OWNED PROPERTY DAMAGE $ HIRED AUTOS X AUTOS _(PER ACCIDENT) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION X TWYTATU0TR- AND EMPLOYERS'�IUTY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N/A 9099073-16 05/09/2016 05/09/2017 E.L.EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? I I (Marmdatoty In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Ifyea_describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Certificate Holder, its directors, officers, employees, agents and volunteers are named as Additional Insured Project *314 Grade 5 Repair Non Phase Work #1 General Liability Endorsement attached with WC Waiver to Follow • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Costa Mesa Sanitary ACCORDANCE WITH THE POLICY PROVISIONS. District AUTHORIZED REPRESENTATIVE 234E 17th Street#205 Costa Mesa,CA 92627 ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 103 GL 0006910-01 ENDT.#002 EFF: 10/0512016 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatlon(s): Location(s)Of Covered Operations The Costa Mesa Sanitary District, Its directors,officers, As required by written contract with Named employees,agents and volunteers. Insured. 234 E 17th Street#205 Costa Mesa, CA 92627 Information required to complete this Schedule, if not shown above,will shown in the Dedarations. A. Section II—Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s)or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for'bodily injury","property This insurance does not apply to "bodily injury"or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions;or ment furnished in connection,with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of the additional insureds at the location of the in the performance of your ongoing operations for insured(s) the additional insured(s)at the location(s)desig- operations has been completed;or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 II 103 GL 0006910-01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resuking from your ongoing operations or"your work'done under a contract with that person or organization and induded in the`products-completed operations hazard"if: a. you agreed to such waiver; b. the waiver is Included as part of a written contract or lease; and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U047-0310 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission. 103 010006910-01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s) (Additional Insured): Location(s)of Covered Operations: All persons or organizations as required by written As designated in written contract with the Named contract with the Named Insured Insured A. SECTION II—WHO IS AN INSURED is amended to include as an additional insured the person(s)or organization(s)shown in the Schedule for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury","property damage"or"personal and advertising injury"caused, in whole or in part, by: 1. Your acts or omissions;or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the locations) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional Insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Uabllity "Bodily injury"or"property damage"for which the additional insured(s)are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work 'Bodily injury"or"property damage"occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project(other than service,maintenance or repairs)to be performed by or on behalf of the additional insured(s)at the location of the covered operations has been completed;or U156P-0310 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. 103 GL 0006810-01 2. That portion ofinjury"your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured "Bodily injury'or'"properly damage"arising directly or indirectly out of the negligence of the additional insured(s). C. SECTION IV — COMMERCIAL GENERAL UAB1LITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U156P-0310 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. 103 GL 0006910.01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION - COMPLETED OPERATIONS & ONGOING OPERATIONS AS SCHEDULED This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Operations All persons or organizations as required by written Commercial, non wrap Projects only as designated contract with the Named Insured by written contract with the Named Insured A. Section II—Who Is An Insured is amended to include the person(s)or organization(s)shown in the Schedule(called additional insured),but only with respect to: (1) Liability for"bodily injury"or"property damage" caused, in whole or in part, resulting from "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and induded In the "products-completed operations hazard" when you and such person(s)or organization(s) have agreed in writing in a con- tract or agreement that such person(s) or organization(s) be named as an additional in- sured on your policy. (2)Liability for"bodily injury", "property damage" or"personal and advertising injury"caused, in whole or in part, by resulting from: (a)Your acts or omissions;or (b)The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the loca- tions)designated above. B. Section IV— Commercial General Liability Conditions, 4. Other Insurance is amended and the following added: If you are required by written contract to provide primary insurance, the insurance afforded by this Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U462-0310 Includes copyrighted material of ISO Properties, Inc.,2004 Page 1 of 1 with its permission. STATUS INQUIRY Preferred Bonding & Insurance Services www.preferredbonding.com 1800 McCollum St. Los Angeles,CA 90026 Tel:(323) 663-7814 *Fax: (323)663-7834 Date:September 22,2016 To: City of Costa Mesa Sanitary District 628 W 19th St Costa Mesa,CA 92626 RE: Bond Number:31656 Surety:Western National Mutual Insurance Company Principal:Tunnelworks Services Inc. Job Description:CMSD Project#314 Grade 5 Phase 4 Repairs. Contract Price:$72,475.00 IF CONTRACT IS COMPLETED, PLEASE ANSWER THESE QUESTIONS: 1. Date of Completion: 2. Date of Acceptance: 3. Final Contract Price, Including Change Orders: 4. Date of Final Payment: DO YOU KNOW OF ANY UNPAID BILLS: YES NO REMARKS: IF CONTRACT IS UNCOMPLETED, PLEASE ANSWER THESE QUESTIONS: 1. Approximate Percentage or Dollar Amount of Contract Completed: 2. Approximate Completion Date: DO YOU KNOW OF ANY UNPAID BILLS: YES NO REMARKS: PLEASE COMPLETE BEFORE RETURNING TO US: DATE: BY: PHONE: TITLE: ADDRESS: Please Have Obligee Complete The Above Status Once Project Is Completed Please forward the information via Mail to the above address, Fax(323)663-7834, Or Email pattvztpreferredbondinq.com 9/30/2016 Company Profile DEPARTMENT OF INSURANCE COMPANY PROFILE Company Profile Company Search Company Information Company Search Results WESTERN NATIONAL MUTUAL INSURANCE COMPANY Company 5350 WEST 78TH STREET Information EDINA, MN 55439 Old Company Names Old Company Names Effective Date Agent for Service Reference Information Agent For Service NAIC Group List NANCY FLORES Lines of Business 818 WEST SEVENTH STREET Workers' SUITE 930 Compensation LOS ANGELES CA 90017 Complaint and Request for Action/Appeals Reference Information Contact Information Financial Statements NAIC #: 15377 PDF's Annual Statements California Company ID #: 5976-6 Quarterly Date Authorized in California: 05/21/2015 Statements Company Complaint License Status: UNLIMITED-NORMAL Company Company Type: Property&Casualty Performance& Comparison Data State of Domicile: MINNESOTA Company Enforcement Action Composite back to top Complaints Studies Additional Info NAIC Group List Find A Company Representative In Your Area NAIC Group #: 0309 WESTERN NATL MUT GRP View Financial Disclaimer Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. SURETY back to top © 2008 California Department of Insurance https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyProfile&doFunction=getCompanyProfile&eid=61235 1/1 10/14/2016 Colony Insurance Company-Company Profile-Best's Credit Rating Center A.M. Best Rating Services Colony Insurance Company (2) A.M.Best#:003283 NAIC#:39993 FEIN#:541423096 Mailing Address View Additional Address Information payRating; P.O.Box 469012 I.BEST San Antonio,TX 78246 - United States A M Assigned to insurance companies that have, in our opinion,an excellent ability to meet their Web:www.colonvsoecialtv.com ongoing insurance obligations. Phone:804-560-2000 Fax:804-560-4820 Based on A.M.Best's analysis,058448-Argo Group International Holdings,Ltd is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure.View a list of operating insurance entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: A(Excellent) Affiliation Code: g(Group) Financial Size Category: XII($1 Billion to$1.25 Billion) Outlook: Stable Action: Affirmed Effective Date: October 22,2015 Initial Rating Date: June 28, 1993 Long-Term Issuer Credit Rating View Definition Long-Term: a Outlook: Stable Action: Affirmed Effective Date: October 22,2015 Initial Rating Date: June 29,2005 u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by:A.M.Best Rating Services,Inc. Senior Financial Analyst:Susan Molineux Director:Jennifer Marshall,CPCU,ARM Disclosure Information FTTle View A.M.Best's Rating Disclosure Form =- A.M.Best Affirms Ratings of Argo Group International Holdings.Ltd.and Subsidiaries;Assigns Ratings to ARIS Title Ins.Corp. October 22,2015 Rating History A.M.Best has provided ratings&analysis on this company since 1993. Financial Strength Effective Date Rating 10/22/2015 A 10/2/2014 A 8/26/2013 A 6/18/2012 A http://www3.am best.com/ratings/entities/CompanyProfi le.aspx?am bnum=3283&U Ratingld=2128297&b1=08AltSrc=9&PPP=&AItN um=0&Ext_User=&Ext_M is... 1/3 10/14/2016 List of Approved Surplus Line Insurers(LASLI) AXIS Specialty Europe SE (Ireland) 06/20/2007 (Name changed from AXIS Specialty Europe Public Limited Company effective 09/10/2012. Name changed from AXIS Specialty Europe Limited effective 04/26/2012) AXIS Surplus Insurance Company(Illinois) ; 12/15/1995 (Name changed from Sheffield Insurance Corporation effective 06/09/2003) Back to Top B - D Date Insurer Approved Berkley Assurance Company(Iowa) 07/20/2011 Berkley Regional Specialty Insurance Company (Delaware) 04/12/2012 Berkshire Hathaway International Insurance Limited (UK) 104/01/2008 The Burlington Insurance Company (Illinois) 111/17/1995 (Domicile changed from North Carolina to Illinois, effective 12/31/2015) Canopius US Insurance, Inc. (Delaware) 07/20/2011 (Name changed from Omega US Insurance, Inc. effective 08/20/2012) Capitol Specialty Insurance Corporation (Wisconsin) !05/15/2008 Catlin Insurance Company(UK) Limited 04/10/2007 Catlin Specialty Insurance Company(Delaware) 06/14/2006 (Name changed from Wellington Specialty Insurance Company effective 03/31/2007) Century Surety Company(Ohio) 09/01/1995 Chubb Custom Insurance Company (New Jersey) 108/04/1995 (Domicile changed from Delaware to New Jersey, effective 04/01/2013) The Cincinnati Specialty Underwrit ance Company(Delaware) —_ —4 01/31/2011 Colony Insurance Company(Virginia) — 09/01/1995 Columbia Casualty Company(Illinois) j 07/06/1995 Covington Specialty Insurance Company(New Hampshire) 1 07/20/2011 Crum & Forster Specialty Insurance Company (Delaware) 04/20/1998 (Name changed from Transnational Insurance Company effective 12/26/2000. Domicile changed from Arizona to Delaware effective 11/21/2014.) j CUMIS Specialty Insurance Company, Inc. (Iowa) 105/15/2008 Back to Top E - G Date Insurer Approved Empire Indemnity Insurance Company(Oklahoma) 12/01/1995 Endurance American Specialty Insurance Company (Delaware) i 02/23/1996 (Name changed from Traders & Pacific Insurance Company effective 06/08/2006) Energy Insurance Mutual Limited (Barbados) 12/17/1997 Evanston Insurance Company (Illinois) 08/11/1995 Everest Indemnity Insurance Company (Delaware) 108/14/1998 Executive Risk Specialty Insurance Company (Connecticut) 109/01/1995 Fair American Select Insurance Company(Delaware) _ — 07/28/2014 http://www.insurance.ca.gov/01-consumers/120-company/07-lasli/lasli.cfm 2/6